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…it’s not just a minor stroke…
APSS Telehealth PresentationTeri Green, RN PhD
Calgary Stroke ProgramFaculty of Nursing/University of Calgary
June 2008
An Examination of Male Patient, Wife-Caregiver, and Marital Dyad Outcomes Over
a Three-Month Period Following Minor Stroke
BACKGROUND
• 50,000 Canadians have a stroke annually; minor stroke or transient ischemic attacks account of 82% of all cerebrovascular disease
• Having a stroke creates a need for short and long-term adjustments for the patient as well as the family
• Minor stroke patients are discharged from acute care
shortly after their stroke event • There is little empirical evidence available regarding:
(a) the effect of minor stroke on patient’s abilities to return to their previous roles and functions; and (b) how this seemingly minor event influences the marital dyad in the immediate post-discharge
period
RESEARCH QUESTIONSPrimary Question
• What are the changes in patient functional status, patient and wife-caregiver health related quality of life (HRQOL) and depression, wife-caregiver strain, and marital dyad functioning between hospital discharge and 3-months following the stroke event?
Secondary Questions• What are the associations between patient functional status, patient and wife-caregiver HRQOL and depression; caregiver strain; and marital dyad functioning over a 3-month period following stroke? • What are the predictors of marital function at 3-months following a minor stroke?
Tertiary Question• What do minor stroke patients and wife-caregivers identify as factors affecting their HRQOL and/or caregiver strain over 3-months following discharge?
RESEARCH METHODS
• Prospective pilot study of 38 male stroke patients and their wife-caregivers
• Demographic and clinical information obtained from the health record and in-person interviews at time of discharge
• Questionnaires administered, using standardized measures, at discharge and one month intervals over a period of 3-months post-stroke using:
• SS-QOL• SF-12v2• BDI-II• FADGFS• BCOS (1-,2-,&3-months)
Inclusion/Exclusion Criteria
Inclusion
• Male patient with a wife-caregiver
• Minor stroke (NIHSS<4, mRS<2, BI>65)
• d/c home within 7 days• MMSE ≥ 24• Able to provide informed
consent• Able to read/speak
English
Exclusion
• No identified spousal caregiver
• Moderate/severe stroke• Extended hospital stay• MMSE < 24• Unable to provide
informed consent• Unable to read/speak
English
DATA ANALYSES• Patients and wife-caregivers characterized using
descriptive statistics
• Correlation analyses to examine relationships between biophysical and psychosocial measures
• Repeated measures ANOVA & MANOVA to examine changes over time
• Logistic regression analysis to determine predictors of marital function at 3-months
• Conventional content analysis of responses to open-ended questions from the Stroke-Specific Quality of Life Scale and the Bakas Caregiver Outcomes Scale administered at 1-, 2-, and 3-months post-discharge
Demographic CharacteristicsPatient Wife-caregiver
Age mean (SD) 63.9 years (12.0)
(range 39-83)
58.5 years (11.7)(range 33-75)
Caucasian n (%) 38 (100) 36 (96)
MMSE mean (SD) 29.5 (1.71) 29.5 (1.49)
Employment Status n(%)
NoYes
Retired
3 (8)25 (66)10 (26)
8 (21)21 (55)9 (24)
Education Level n (%)≤ high school
High School graduatePost-secondary
7(18)13 (34)18 (47)
3 (8)8(21)
27 (71)
Stroke Characteristics
• Stroke Type: ischemic 36 (95%), hemorrhagic 2 (5%)
• Lesion Side: right 21 (55%), left 17 (45%)
• Location: supratentorial 27 (63%), brainstem 4 (11%), unknown 7 (18%)
Stroke Severity & Functional Outcomes
Paired t-test
Discharge X (SD)
3-monthsX (SD)
t(df) p
NIHSS(0-42)
2.0 (1.70) 1.1 (2.38)
1.87 (37)
0.076
mRS(o-6)
1.4 (0.95) 1.0 (0.75)
2.34 (37)
0.025*
BI(0-100)
93.2 (12.44)
98.6 (8.13)
-2.22 (37)
0.033*
SIS-16(16-80)
74.0 (8.26) 74.6 (7.05)
-3.91 (37)
0.698
Changes in Psychosocial Measures between Discharge and 3-months
Post-dischargeANOVA
DischargeX (SD)
3-monthsX (SD) F (df) p
SS-QOL (1-5) 4.08 (.504) 4.17 (.479) 1.06 (3) 0.311
SF-12 (0-100)Physical
Mental Health
51.07 (9.45)49.20 (9.95)
51.02 10.09)51.10 10.64)
0.039 (3)1.69 (3)
0.9890.186
BCOS (15-105)1 and 3-mo
57.13 (8.70) 57.80 (8.70) 0.201 (2) 0.819
Changes in Depression and Marital Function between
Discharge and 3-months Post-discharge
Discharge
X (SD)
3-months
X (SD)
MANOVA
t(df) p
BDI-II (0-63)Patient
Wife-caregiver
6.18 (6.70)7.21 (5.73)
6.0 (6.64)6.39 (3.50)
2.67(3) 0.063
FADGFS (1-4)Patient
Wife-caregiver
1.58 (.503)1.73 (.471)
2.0 (.428)1.83 (.519)
3.75 (3) 0.025*
Patient and Wife-caregiver Mean BDI-II Scores Over Time
Three months post-discharge
(p=0.904)
Two month post-discharge (p=0.610)
One month post-discharge (p=0.018)
Discharge (p=0.456)
8.0
7.5
7.0
6.5
6.0
5.5
5.0
5.97
5.21
5.42
7.21
7.26
6.66
7.53
6.18
Patients
Wife-ca
regive
rs
Patient and Wife-caregiver Mean FADGFS Scores Over
Time
Three months post-discharge
(p=0.551)
Two months post-discharge (p=0.278)
One month post-discharge (p=0.000)
Discharge (p=0.001)
1.9
1.8
1.7
1.6
1.821.821.82
1.73
1.88
1.891.92
1.58
Patients
Wife-caregivers
Associations Between Outcome Variables
Patient: • HRQOL & depression
• r=-.577, p<0.001 (discharge)• r=-.662, p<0.001 (1-month post-discharge)• r=-.495, p=0.002 (2-months post-discharge) • r=-.758, p<0.001 (3-months post-discharge)
• Depression & wife-caregiver’s perception of marital function
• r=.442, p=0.005 (discharge)• r=.376, p=0.020 (2-months) • r=.610, p<0.001 (3-months)
Associations Between Outcome Variables
Wife-caregiver:• Depression & wife-caregiver’s perception of
marital function • r =.362, p=0.026 (discharge)• r=.538, p<0.001 (1-month)• r=.334, p=0.040 (2-months)• r=.578, p<0.001 (3-months)
• Wife-caregiver’s perception of marital function and caregiver strain
• r=-.517, p<0.001 (1-month)• r=-.742, p<0.001 (2-months)• r=-.620, p<0.001 (3-months)
Predictors of Marital Function at
3-monthsOR 95% CI p
mRS . 270 .081 - .902 0.033*
SS-QOL .032 .001 - .987 0.049*
SF-12 physical
1.257 1.035 – 1.526
0.021*
BCOS .739 .543 – 1.005
0.054
Qualitative Data
• Transitional framework* “Passage from one life condition or status to another “
o processo timeo perception
• **Content analysis
*Chick & Meleis (1986). Transitions: A Nursing Concern
Hsieh & Shannon (2005)
Content Analysis
• Overarching Themes– Being vulnerable– Realization of the new self and changing
relationships
• Subthemes• Masculine image• Hyper-vigilance• Loss
Being Vulnerable
• Uncertainty– Fear of recurrent stroke – vulnerable to
the disease
• Frustration over recovery process• Lack of assurance about the future
- health status- work and financial situations- lifestyle
Being Vulnerable
• Gossiped about• Stigmatized• Isolated & abandoned• Insecure• Financial/work stability challenged• Mood changes and stress
Realization
• Increasing awareness and insight• Apprehension about ability to put
their lives back together - Continuity of the family- Maintenance of relationships
• Adaptation– Acceptance and denial– Incorporation of physical deficits– Ongoing challenges of emotional and
cognitive changes– Stabilization – changing priorities– Recognition of need for continuous
adaptation
Key Threads
• Masculinity: imposed limitations, life-changes
• Hyper-vigilance: protective monitoring, control
• Loss: physical, emotional, social
Masculinity
• “I was surprised by the long term effects of the stroke…not prepared for the loss of energy and changes in mood, thinking and personality.”
• “The stroke has made me useless. I can’t do the things for my family like protect them. If an intruder came in I couldn’t even defend my family. I wouldn’t even have the strength to fight off a child.”
Masculinity
• “The largest challenge has been the feelings of depression that have been part of life since the stroke. It’s a struggle to accept that I am not the person I used to be, that I can’t contribute like I used to, it seems like I’m not worthwhile as I was before.”
• “…I am feeling blue and I cry at the drop of a hat…fear and anxiety are new to me.”
Hyper-vigilance • “always watching”
• “Since I am his wife and I am the one closest to him, the only one who can really take care of him, I really do feel this as a responsibility and yet it is so different to have him here in my space…”
• “…my husband would kill me if he knew that I check on him in the night to see if he is still breathing.”
• “My husband accuses me of babying him, but my over-protectiveness is an automatic reaction because I am afraid to let him go.”
Loss
• “I am feeling the burden of having to make many life decisions because my husband doesn’t want to make any decisions himself.”
• “I feel trapped by my husband and sometimes I would like to run away…I have to spend all my time with him and this has negatively impacted my relationship with friends and family.”
• “I am feeling overwhelmed…the whole family system is disrupted.”
Loss
• “…marital relationship is tense and negative with arguments over everything.”
• “I am not the same person that I was before.”
• “I always pride myself in being healthy and athletic, now I feel so weak. Physically I am going soft.”
Participant’s Personal Reflections
• “There is more to life than tangibles, and I have learned to count my blessings.”
• “I realize how devastating the stroke could have been…I am humbled by everything and I am most grateful.”
• “…more reflective and more aware of what is important…”
• “I am entering a transitional period, where I will have to learn to get over my past perceptions of self-image. Perhaps it is time to focus on other things…Previously I had a dichotomy between my physical and emotional needs. The stroke has highlighted the need to develop all aspects of myself in order to have a better quality of life. It has taught me the importance of moderation and balance.”
CONCLUSIONS…it’s not just a minor stroke…
• Patients experienced significant improvement in functional status over time however overall psychosocial status did not improve from time of discharge
• Though patients perceived a deterioration in marital function over time, wife-caregiver scores did not change significantly (on any of the psychosocial measures)
Conclusions
• Qualitatively, patients and wife-caregivers reported difficulty returning to previous life roles (including family, work, and social roles) over the 3-month period
• The lack of complete functional recovery over time created a disconnect between the hope and the reality of having a ‘minor’ event